Tobacco use in young people: being emic to end the epidemic

In their Article in The Lancet Public Health, Marissa Reitsma and colleagues1Reitsma MB Flor LS Mullany EC Gupta V Hay SI Gakidou E Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and initiation among young people in 204 countries and territories, 1990–2019.Lancet Public Health. 2021; (published online May 27.)https://doi.org/10.1016/S2468-2667(21)00102-XSummary Full Text Full Text PDF Scopus (5) Google Scholar report their comprehensive analysis of smoking tobacco use in young people from more than 3000 tobacco surveys from 204 countries and territories around the world. The result is an invaluable overview of an epidemic that causes millions of deaths every year. Their detailed mapping of the prevalence of smoking tobacco use in young people (aged 15–24 years) will be a reference for policy and research in the years to come. Moreover, the authors documented two important general patterns. First, most tobacco smokers (65·5% [95% uncertainty interval (UI) 64·3–66·5]) started smoking before age 20 years. Although this early initiation of smoking is well known, Reitsma and colleagues show that this pattern persists across most of the world.1Reitsma MB Flor LS Mullany EC Gupta V Hay SI Gakidou E Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and initiation among young people in 204 countries and territories, 1990–2019.Lancet Public Health. 2021; (published online May 27.)https://doi.org/10.1016/S2468-2667(21)00102-XSummary Full Text Full Text PDF Scopus (5) Google Scholar They found some exceptions, mostly among females in countries in the early stages of the tobacco epidemic. But in other countries, smoking is initiated in the next the generation mostly during middle and late adolescence (age 15–20 years). Therefore, this period of life is essential to stop what could be an intergenerational transmission of smoking. Second, the prevalence of smoking in young people has decreased at the global level by approximately 33% over the past 30 years.1Reitsma MB Flor LS Mullany EC Gupta V Hay SI Gakidou E Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and initiation among young people in 204 countries and territories, 1990–2019.Lancet Public Health. 2021; (published online May 27.)https://doi.org/10.1016/S2468-2667(21)00102-XSummary Full Text Full Text PDF Scopus (5) Google Scholar Decreasing prevalences of smoking were observed in most regions globally, with decreases between 1990 and 2019 of up to 50% in Latin America and the Caribbean. However, some exceptions exist, for example, non-significant increases in prevalence were observed among females in two super-regions: north Africa and the Middle East and southeast Asia, east Asia, and Oceania. Moreover, the decreases in the past 30 years were generally too slow to end the epidemic within one generation. This finding highlights the need for additional efforts to reach the ambitious target of a smoke-free generation.2Johannesen CK Andersen S Bast LS Estimating future smoking in Danish youth - effects of three prevention strategies.Scand J Public Health. 2020; (https://doi.org/10.1177%2F1403494820942678 published online Aug 14.)Crossref PubMed Scopus (1) Google Scholar Reitsma and colleagues provide a list of policy options to address smoking tobacco use in young people. In line with international recommendations and conventions, they emphasise product-oriented and environmental policies.3WHOWHO report on the global tobacco epidemic 2019. World Health Organization, Geneva2019https://www.who.int/teams/health-promotion/tobacco-control/who-report-on-the-global-tobacco-epidemic-2019Date accessed: May 17, 2021Google Scholar These policies might affect the prevalence of smoking in young people by making tobacco smoking in society less visible, acceptable, accessible, or affordable. Moreover, ample evidence exists on the effectiveness of these policies in reducing smoking tobacco consumption in adults.4Gravely S Giovino GA Craig L et al.Implementation of key demand-reduction measures of the WHO Framework Convention on Tobacco Control and change in smoking prevalence in 126 countries: an association study.Lancet Public Health. 2017; 2: e166-e174Summary Full Text Full Text PDF PubMed Scopus (108) Google Scholar Given the described transmission of smoking patterns from parents to children,5Ikram UZ Snijder MB Derks EM Peters RJG Kunst AE Stronks K Parental smoking and adult offspring's smoking behaviors in ethnic minority groups: an intergenerational analysis in the HELIUS study.Nicotine Tob Res. 2018; 20: 766-774Crossref PubMed Scopus (2) Google Scholar decreases in the prevalence of smoking among adults might be the prelude to similar decreases in young people. Yet, we cannot take for granted that policies will have similar effects on smoking in young people as they have had on adult smoking. Evaluating policies specifically with regards to their effect on smoking in young people is important. Assessments of tobacco taxation policies have mostly confirmed the expected effect: higher prices lead to lower rates of smoking initiation.6Apollonio DE Dutra LM Glantz SA Associations between smoking trajectories, smoke-free laws and cigarette taxes in a longitudinal sample of youth and young adults.PLoS One. 2021; 16e0246321Crossref PubMed Scopus (2) Google Scholar Unfortunately, most other policies were less often studied for their effect on smoking in young people. For example, the effect of smoke-free workplaces, bars, and restaurants has been addressed in numerous studies on smoking in adults, but in only a dozen studies on smoking in young people (Kuipers M, Amsterdam UMC, personal communication). When policies were assessed for their effect on smoking tobacco use in young people, the findings were too often inconclusive. For example, although smoke-free school policies were associated with reduced smoking among young people in some studies, other studies found no effect.7Schreuders M van den Putte B Kunst AE Smoke-free school policies in Europe: challenges for the future.Prev Med. 2020; 138106130Crossref PubMed Scopus (5) Google Scholar Although the inconsistencies do not deny the potential benefits of policies of smoke-free schools, they are a warning signal that these benefits might or might not be reaped in practice, depending on how the policies are implemented and enforced.7Schreuders M van den Putte B Kunst AE Smoke-free school policies in Europe: challenges for the future.Prev Med. 2020; 138106130Crossref PubMed Scopus (5) Google Scholar How these policies take into account the experiences and views of the students is crucial. In-depth assessments have shown that young people might respond to policies in ways unforeseen by adult observers. When tobacco smoking is banned from schools, students might respond by shifting towards smoking at other times and in other places.8Lagerweij NA Kunst AE Mélard N et al.Where do teens smoke? Smoking locations of adolescents in Europe in relation to smoking bans in bars, schools and homes.Health Place. 2019; 60102213Crossref PubMed Scopus (1) Google Scholar When the cost of cigarettes is increased, young people might respond by increasing their monetary income rather than decreasing consumption.9Perelman J Alves J Pfoertner TK et al.The association between personal income and smoking among adolescents: a study in six European cities.Addiction. 2017; 112: 2248-2256Crossref PubMed Scopus (15) Google Scholar When adolescents are not permitted to buy cigarettes, they might be ready to use diverse tactics to buy cigarettes or to involve social networks with older peers to ensure easy access.10Nuyts PAW Hewer RMF Kuipers MAG et al.Youth access to cigarettes across seven European countries: a mixed-methods study.Nicotine Tob Res. 2020; 22: 1989-1996Crossref PubMed Scopus (3) Google Scholar Accessing young people's views, experiences, and responses could aid understanding of why policies might have little or variable impact. Such measures should also be extended to low-income settings. For example, in Indonesia, radio and television advertisements are banned at so-called youth times, but young people still report frequent exposure to tobacco promotion on social media or at sports events.11Septiono W Kuipers MAG Ng N Kunst AE Self-reported exposure of Indonesian adolescents to online and offline tobacco advertising, promotion and sponsorship (TAPS).Tob Control. 2021; (published online Feb 19.)https://doi.org/10.1136/tobaccocontrol-2020-056080Crossref PubMed Scopus (3) Google Scholar Such insights could inform attempts to make policies more effective (eg, expanding advertisements bans) and could inform the tailoring of actions for specific groups of young people.7Schreuders M van den Putte B Kunst AE Smoke-free school policies in Europe: challenges for the future.Prev Med. 2020; 138106130Crossref PubMed Scopus (5) Google Scholar Insights into tobacco smoking in young people might not only come from quantitative approaches such as analysis of health surveys,1Reitsma MB Flor LS Mullany EC Gupta V Hay SI Gakidou E Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and initiation among young people in 204 countries and territories, 1990–2019.Lancet Public Health. 2021; (published online May 27.)https://doi.org/10.1016/S2468-2667(21)00102-XSummary Full Text Full Text PDF Scopus (5) Google Scholar but also from qualitative approaches such as in-depth interviews, focus group discussions, and participatory research. Qualitative approaches such as these aim for an emic (insider) rather than an etic (outsider) perspective. Emic approaches might aid understanding of how young people might become addicted, what they need to stay smoke-free, and how policies can best help and protect them. In short, to inform policies to end the tobacco epidemic, we need approaches that are emic as well as etic. I declare no competing interests. Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and initiation among young people in 204 countries and territories, 1990–2019The fact that most smokers start smoking regularly before age 20 years highlights the unique window of opportunity to target prevention efforts among young people and save millions of lives and avert health-care costs in the future. Countries can substantially improve the health of their populations by implementing and enforcing evidence-based tobacco control policies that prevent the next generation from initiating smoking.